X21041-R2 Effective Date: 01/01/2019 Group Number: 10422797

BLUE CROSS AND BLUE SHIELD OF MINNESOTA

VALUE STANDARD OPTION 2 GROUP VISION BENEFIT BOOKLET

X21041-R2 Effective Date: 01/01/2019 Group Number: 10422797

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LANGUAGE ACCESS SERVICES

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TABLE OF CONTENTS LANGUAGE ACCESS SERVICES ........................................................................................................ 3

CUSTOMER SERVICE ........................................................................................................................... 7

COVERAGE INFORMATION ................................................................................................................. 8 Your Benefits ...................................................................................................................................... 8 Choice of Provider .............................................................................................................................. 8 Covered Services ................................................................................................................................ 8 Premium Payment............................................................................................................................... 8 Payment of Benefits ............................................................................................................................ 9 Services that are not Covered............................................................................................................. 9 Fraudulent Practices ........................................................................................................................... 9 Time Periods ....................................................................................................................................... 9

BENEFITS ............................................................................................................................................ 10 Schedule of Benefits ......................................................................................................................... 10

DAVIS VISION COLLECTION ............................................................................................................. 12

SCHEDULE OF EXCLUSIONS ............................................................................................................ 13

ELIGIBILITY ......................................................................................................................................... 15 Eligible Dependents .......................................................................................................................... 15 Effective Date of Coverage ............................................................................................................... 16 Adding New Dependents .................................................................................................................. 16 Special Enrollment Periods ............................................................................................................... 16

CONTRACT TERM AND RENEWAL ................................................................................................... 19 Benefits After Coverage Terminates ................................................................................................. 19

CONTINUATION OF COVERAGE ....................................................................................................... 20

REIMBURSEMENT AND SUBROGATION ......................................................................................... 27

GENERAL PROVISIONS ..................................................................................................................... 28 Release of Records .......................................................................................................................... 28 Entire Contract .................................................................................................................................. 28 Time Limit for Misstatements ............................................................................................................ 28 Indemnity for Loss of LIfe .................................................................................................................. 28 Change of Beneficiary ....................................................................................................................... 29 Changes to the Contract ................................................................................................................... 29 Assignment ....................................................................................................................................... 29 Conformity with State Laws............................................................................................................... 29 Legal Actions .................................................................................................................................... 29 No Third-Party Beneficiaries ............................................................................................................. 29 Prior Approval ................................................................................................................................... 30

CLAIM PROVISIONS ........................................................................................................................... 31 Notice of Claim .................................................................................................................................. 31 Claim Forms ...................................................................................................................................... 31 Proof of Loss ..................................................................................................................................... 31 Time Payment of Claims ................................................................................................................... 31 Payment of Claims ............................................................................................................................ 31 Physical Examinations ...................................................................................................................... 32

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Review of a Benefit Determination .................................................................................................... 32

APPEAL PROCESS ............................................................................................................................. 33 Appeal Procedures ........................................................................................................................... 33 Expedited Appeal .............................................................................................................................. 34 Standard Appeal ............................................................................................................................... 34 External Review ................................................................................................................................ 34 Expedited External Review ............................................................................................................... 34 Standard External Review................................................................................................................. 35

DEFINITIONS ....................................................................................................................................... 36

EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA) STATEMENT OF RIGHTS ............. 39

MINNESOTA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION NOTICE ................... 41

NOTICE OF PRIVACY PRACTICES ..................................................................................................... 42

NOTICE OF OUR FINANCIAL INFORMATION PRIVACY POLICIES AND PRACTICES .................... 46

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CUSTOMER SERVICE

Questions? Our customer service staff is available to answer questions about your coverage.

Interpreter services are available to assist you if needed. This includes spoken language and hearing interpreters.

Monday through Friday: 7:00 a.m. - 8:00 p.m. United States Central Time

Hours are subject to change without prior notice.

Customer Service Telephone Number

For claims and benefit inquiries call 1-888-444-5591.

For all other inquiries please call 1-866-870-0348.

Blue Cross and Blue Shield of Minnesota Website

www.bluecrossmnonline.com

Mailing Address Claims review requests and inquires may be mailed to the address below:

Vision Care Processing Unit P.O. Box 1525 Latham, NY 12110

IMPORTANT! We issue each Group Member an identification (ID) card. If any of the information on your ID card is not correct, please contact us immediately. When receiving care, present your ID card to the Vision Care Provider who is rendering the services. A copy of our privacy procedures is available on our website or by calling Customer Service at 1-800-382-2000.

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COVERAGE INFORMATION

Your Benefits This Benefit Booklet outlines the vision coverage under this plan. Please be certain to check the “Schedule of Benefits” section to identify covered benefits. You must also refer to the “Schedule of Exclusions” section to determine if services are not covered. If you have questions, call Customer Service at the telephone number on the back of your ID card. Vision Care Providers are not beneficiaries under this Benefit Booklet. All coverage of benefits for dependents and all references to dependents in this Benefit Booklet are inapplicable for employee-only coverage.

Choice of Provider Covered Persons may choose any licensed Vision Care Provider for services. However, choosing a Participating Vision Care Provider, may limit Out-of-Pocket Expenses. Participating Vision Care Provider limit their fees to their contracted Maximum Allowable Charges for Covered Services. Also, if agreed by the Vision Care Provider, Participating Vison Care Providers limit their charges for all services delivered to Covered Persons, even if the service is not covered for any reason and a benefit is not paid under this Benefit Booklet. Participating Vision Care Providers also complete and send claims for Covered Services directly to Us for processing. To find a Participating Vision Care Provider, visit Our website at www.bluecrossmnonline.com or call the toll-free number on Your ID card. When using a Non-Participating Vision Care Provider, You may have to pay the Vision Care Provider at the time of service, complete and submit Your own claims and/or wait for Us to reimburse You. You will be responsible for the Vision Care Provider’s full charge which may exceed Our Maximum Allowable Charge and result in higher Out-of-Pocket Expenses.

Covered Services Benefits and any applicable Deductibles, and Maximums are shown on the “Schedule of Benefits.” No benefits will be provided for services, supplies or charges detailed under the Exclusions on the “Schedule of Exclusions.” Services shown on the “Schedule of Benefits” as covered are subject to Frequency or age limitations detailed on the attached “Schedule of Exclusions.” Referrals are not required. Your Vision Care Provider may suggest that you receive treatment from a specific Vision Care Provider or receive a specific treatment. Even though your Vision Care Provider may recommend or provide written authorization for a referral for certain services, the Vision Care Provider may be a Non-Participating Vision Care Provider or the recommended services may be excluded or limited. When these services are referred or recommended, a written authorization from your Vison Care Provider does not override any provisions in the “Schedule of Benefits” or the “Schedule of Exclusions.” This Benefit Booklet provides coverage of benefits for a pre-determined schedule of vision services. While other vision services may be recommended, they may not be covered under this Benefit Booklet. At Your option, You may wish to obtain a pre-treatment estimate to determine whether a vision service is a covered benefit under this Benefit Booklet. A pre-determination will provide You with information on whether the vision service is covered and what You may be financially responsible for paying. Coverage of benefits and any financial estimate provided by a pre-treatment determination are estimated based on Your current eligibility and Benefit Booklet at the time of the request. Your actual coverage of benefits, including a final determination on coverage and payment, will be processed based on the claim submitted and Your eligibility and Benefit Booklet at the time the vision service is performed and submitted.

Premium Payment We charge your employer a monthly rate (Premium). We may revise this rate during the plan year due to changes in the group's status. Your monthly contribution amount (if any) is determined by your employer.

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Payment of Benefits When treatments are performed by a Participating Vision Care Provider, We will pay covered benefits directly to the Participating Vision Care Provider. Both You and the Vision Care Provider will be notified of benefits covered, Our payment and any Out-of-Pocket Expenses. Payment will be based on the Maximum Allowable Charge the treating Participating Vision Care Provider has contracted to accept. Maximum Allowable Charges may vary depending on the geographical area of the vision office and the contract between Us and the particular Participating Vision Care Provider rendering the service. Participating Vision Care Providers agree by contract to accept Maximum Allowable Charges as payment in full for Covered Services rendered to Covered Persons. When treatments are performed by a Non-Participating Vision Care Provider, benefits are substantially reduced and You will likely incur significantly higher Out-of-Pocket Expenses. We will either send payment for Covered Services to You or We may choose to pay the Non-Participating Vision Care Provider. You will still be notified of the services covered, Our payment and any Out-of-Pocket Expenses. When We pay the Vison Care Provider, We have met our obligation under the Benefit Booklet. You may not assign Your right, if any, to commence legal proceedings against Blue Cross. Our payment will be based upon the Maximum Allowable Charge for a Covered Service. You will be responsible to pay the Vision Care Provider any difference between Our payment and the Vision Care Provider’s full charge for the services. Non-Participating Vision Care Providers are not obligated to limit their fees to Our Maximum Allowable Charges. The above is a general summary of Our Vision Care Provider payment methodologies only. While efforts are made to keep this information as up to date as possible, payment methodologies may change from time to time and every current Vision Care Provider payment methodology may not be reflected in this summary. Please note that some of these payment methodologies may not apply to your Benefit Booklet. We are not liable to pay benefits for any services started prior to a Covered Person’s Effective Date of coverage. Procedures started prior to the Covered Person’s Effective Date are the liability of the Covered Person. This Benefit Booklet does not coordinate benefits with other vision care plans.

Services that are not Covered No payment of benefits will be allowed under this Plan including payments for services you have already received.

Fraudulent Practices Coverage for You and/or Your Dependent(s) will be terminated if You and/or Your Dependent(s) engage in fraud of any type or intentional misrepresentation of material fact including, but not limited to: submitting fraudulent misstatements or omissions about your vision history or Eligibility status on the enrollment form for coverage; submitting fraudulent, altered, or duplicate billings for personal gain; and/or allowing another party not eligible for coverage under the Benefit Booklet to use Your and/or Your Dependent's coverage.

Time Periods When the time of day is important for benefits or determining when coverage starts and ends, a day begins at 12:00 a.m. United States Central Time and ends at 12:00 a.m. United States Central Time the following day.

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BENEFITS This Benefit Booklet provides benefits for vision care only. It does not pay benefits for any other type of loss.

SCHEDULE OF BENEFITS

Participating Vision Care Provider (In-Network) Benefits Value Standard Option 2

Frequency – Once Every:

Eye Examination inclusive of Dilation (when professionally indicated)

12 Months

Spectacle Lenses 12 Months

Frame 24 Months

Contact Lens Evaluation, Fitting & Follow-Up Care (in lieu of eyeglasses)

12 Months

Contact Lenses (in lieu of eyeglasses) 12 Months

Copayments

Eye Examination $10

Retinal Imaging $39

Spectacle Lenses $25

Contact Lens Evaluation, Fitting & Follow-Up Care $25

Eyeglass Benefit - Frame

Frame Allowance (Retail): Up to $130 OR

Up to $1801 Plus a 20% Discount on any overage2

Davis Vision Frame Collection3 (in lieu of Allowance):

Fashion level Included

Designer level Included

Premier level $25 Copayment

Eyeglass Benefit - Spectacle Lenses Member Charges

Clear plastic single-vision, lined bifocal, trifocal or lenticular Lenses (any size or Rx)

100% after $25 Copayment

Tinting of Plastic Lenses Included

Scratch-Resistant Coating Included

Polycarbonate Lenses (Children4/Adults) $0 / $30

Ultraviolet Coating $12

Anti-Reflective (AR) Coating (Standard/Premium/Ultra) $35 / $48 / $60

Progressive Lenses (Standard/Premium/Ultra) $50 / $90 / $140

High-Index Lenses $55

Polarized Lenses $75 $75

Plastic Photochromic Lenses $65

Scratch Protection Plan: Single Vision/Multifocal Lenses $20 / $40

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Contact Lens Benefit (in lieu of eyeglasses)

Contact Lens: Materials Allowance Up to $130 Plus a 15% Discount on any overage2

Evaluation, Fitting & Follow-Up Care – Standard Lens Types 100% after $25 Copayment

Evaluation, Fitting & Follow-Up Care – Specialty Lens Types $25 Copayment, plan pays up to $60 Allowance

Plus a 15% Discount on any overage2

Visually required contact Lenses (preauthorization required)

Materials Included

Evaluation, fitting and follow-up care 100% after $25 Copayment

Collection Contact Lenses3 (in lieu of Allowance): Materials

Disposable: up to 4 boxes/multi-packs

Planned Replacement: up to 2 boxes/multi-packs

Evaluation, Fitting & Follow-up Care 100% after $25 Copayment

Laser vision correction (LASIK)

One-time/Lifetime Allowance $200

Non-Participating Vision Care Provider (Out-of-Network) Reimbursement Schedule: up to

Eye Examination: $40

Single Vision Lenses: $40

Trifocal Lenses: $80

Elective Contact Lenses: $105

Frame: $50

Bifocal/Progressive Lenses: $60

Lenticular Lenses: $100

Visually required (preauthorization required): $225

1. Enhanced frame Allowance available at all Visionworks locations nationwide.

2. Additional Discounts not applicable at Walmart, Sam’s Club or Costco locations.

3. Collection is available at most participating independent provider offices. Collection is subject to change. Collection is inclusive of select torics and multifocals.

4. Polycarbonate Lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

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DAVIS VISION COLLECTION In lieu of the frame Allowance, Covered Persons may choose to select any frame from the Davis Vision’s Collection. The Collection is available at most participating independent provider offices and features three levels of frames. In lieu of the non-Collection contact lens Allowance, Covered Persons may be fitted with contact Lenses from the Davis Vision Collection. Contact Lenses from the Davis Vision Collection include the evaluation, fitting and follow-up care. Examination

An Exam or Eye examination includes (but is not limited to):

• Case history – chief complaint, eye and vision history, medical history

• Entrance distance acuities

• External ocular evaluation including slit lamp examination

• Internal ocular examination

• Tonometry

• Distance refraction – objective and subjective

• Binocular coordination and ocular motility evaluation

• Evaluation of pupillary function

• Biomicroscopy

• Gross visual fields

• Assessment and plan

• Advising on matters pertaining to vision care

• Form completion – school, motor vehicle, etc.

• Dilated Fundus Examination (DFE) (diagnostic procedure used in the detection and management of diabetes, glaucoma, hypertension and other ocular and/or systemic diseases) when professionally indicated.

The Covered Person’s benefit is paid in full up to the maximum Allowance during each Frequency period. Any amount due over the Allowance for such Lenses during the Frequency period is the Covered Person’s responsibility. Contact lens evaluation, fitting and follow-up care applies to standard daily wear, disposable, planned replacement, specialty contact lens benefit. Davis Vision is an independent company providing vision benefit management services and access to the Davis network. Each vision provider is an independent contractor and not our agent. It is up to the member to confirm provider participation in their network prior to receiving services.

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SCHEDULE OF EXCLUSIONS Except as specifically provided in this booklet, no program payment will be made for services or charges for: 1. examinations, Materials or products which are not listed herein as a Covered Service;

2. medical or surgical treatment of eye disease or injury;

3. for visual therapy;

4. procedures determined by Blue Cross to be special or unusual, such as but not limited to, orthoptics, vision training and tonography;

5. any Covered Service not shown in the “Schedule of Benefits” or any expenses shown as “Not Covered” in the “Schedule of Benefits.”

6. Eye Examinations or Materials necessitated by your employment or furnished as a condition of employment;

7. services or Materials provided in connection with special procedures such as orthoptics and visual training (including but not limited to “Corneal Refractive Therapy” (“CRT), or “orthokeratology”), or in connection with medical or surgical treatment (including laser vision correction) except as provided herein;

8. laser vision correction except as provided herein;

9. Materials which do not provide vision correction, except as provided herein;

10. services that are provided to you for the treatment of an employment related illness/injury for which you are entitled to make a worker’s compensation claim, unless the worker’s compensation carrier has disputed the claim;

11. to the extent benefits are provided by any governmental unit, unless payment is required by law;

12. which you would have no legal obligation to pay in the absence of this or any similar coverage;

13. received from a medical department maintained, in whole or in part, by or on behalf of an employer, a mutual benefit association, labor union, trust, or similar person or group;

14. telephone consultations, charges for failure to keep a scheduled visit, or charges for completion of a claim form;

15. temporary devices, appliances and services;

16. treatment, services or supplies that are provided at no charge;

17. the cost of which has been or is later recovered in any action at law or in compromise or settlement of any claim except where prohibited by law;

18. in a facility performed by a professional provider who is compensated by the facility for similar Covered Services performed for you;

19. to the extent payment has been made under Medicare when Medicare is primary or would have been made if you had applied for Medicare and claimed Medicare benefits; however, this Exclusion shall not apply when the group is obligated by law to offer you all the benefits of this program and you so elect this coverage as primary;

20. treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insured plan, or payable in any manner under any state law governing liability for injuries arising from the maintenance or use of a motor vehicle;

21. any condition caused by or resulting from declared or undeclared war or act thereof, or resulting from service in the National Guard or in the Armed Forces of any country or international authority;

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22. incurred as a result of an intentionally self-inflected injury or injury sustained while committing a crime;

23. services or supplies furnished to a Covered Person before the Effective Date of insurance under this Benefit Booklet or after the date a Covered Person’s Insurance ends;

24. services rendered by practitioners who do not meet the definition of Provider;

25. expenses covered by any other group insurance;

26. expenses covered by a health maintenance organization or hospital or medical services prepayment plan available through an employer;

27. the cost of any insurance Premiums indemnifying you against losses for Lenses or frames;

28. non-prescription industrial safety glasses and safety goggles;

29. sports glasses;

30. incurred after the date of termination of your coverage except for Lenses and frames prescribed prior to such termination and delivered within 31 days from such date;

31. duplicate devices, appliances and services;

32. any Lenses which do not require a prescription;

33. prosthetic devices and services;

34. comprehensive low vision evaluations, subsequent follow-up visits following such evaluation or low vision aids for which prior approval was not obtained from Us or our authorized representative;

35. visually required contact Lenses prescribed for a Covered Person for which prior approval was not obtained from Us or our authorized representative;

36. refraction-only claims;

37. non-prescription (Plano) Lenses;

38. special lens designs or coatings not otherwise specified herein;

39. charges for the replacement of lost or stolen eyeglass Lenses or frames or lost, stolen or damaged contact Lenses and safety eyeglasses within the applicable benefit Frequency period in the “Schedule of Benefits”;

40. replacement of broken frames and eyeglass Lenses;

41. replacement of lost, damaged or broken safety eyeglasses supplied by Davis Vision's ophthalmic laboratories or any other manufacturer;

42. additives for glass Lenses or contact Lenses not otherwise specified herein; and

43. sales tax and shipping charges that may be associated with purchases of post-refractive products covered herein.

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ELIGIBILITY

Eligible Dependents NOTE: If both you and your Spouse are Group Members of the group contractholder, you may be covered as either an Employee or as a Dependent, but not as both. Your eligible Dependent children may be covered under either parent’s coverage, but not both.

This Benefit Booklet covers only those Group Members who work in the United States (U.S.) or its Territories. Group members who work and reside in foreign countries are not eligible for coverage. Employees who are U.S. citizens or permanent residents of the U.S. working outside of the U.S. on a temporary basis are eligible. Spouse

Spouse, meaning:

1. The Group Member legally married Spouse or by any union between two (2) adults that is recognized by law in the state where this Benefit Booklet is issued.

[

Dependent Children [

1. Children of a legal marriage to the Dependent Limiting Age.

2. Natural-born Dependent children and/or stepchildren to the Dependent Limiting Age.

3. Legally adopted children and children placed with you or your Spouse for legal adoption to the Dependent Limiting Age. Date of placement" means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The child's placement with a person terminates upon the termination of the legal obligation of total or partial support.

4. Dependent children for whom you or your Spouse have been appointed legal guardian to the Dependent Limiting Age.

5. Foster children placed with you or your Spouse by an authorized placement agency or by judgment decree, or other order of any court of competent jurisdiction.

6. Grandchildren to the Dependent Limiting Age who live with you or your Spouse continuously from birth and are financially dependent upon you or your Spouse.

7. Otherwise eligible children of the Group Member who are required to be covered by reason of a Qualified Medical Child Support Order to the Dependent Limiting Age.

Disabled Dependents

1. Disabled Dependent children after reaching the Dependent Limiting Age while covered under this Plan if all of the following apply:

a. primarily dependent upon the Group Member; and,

b. are incapable of self-sustaining employment because of physical disability, developmental disability, mental illness, or mental disorders; and,

c. for whom application for extended coverage as a disabled dependent child is made within 31 days after reaching the Limiting Age. After this initial proof, we may request proof again two (2) years later, and each year thereafter; and,

d. must have become disabled prior to reaching the Limiting Age.

2. Disabled Dependents if both of the following apply:

a. incapable of self-sustaining employment by reason of developmental disability, mental illness or disorder, or physical disability; and,

b. chiefly dependent upon the Group Member for support and maintenance.

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Effective Date of Coverage Coverage for the Group Member and any Dependents who are eligible on the Effective Date of the contract begins on that date. For Group Members added after the original Effective Date of the contract, coverage will take effect on the date the Group Member has satisfied the group contractholder's eligibility and probationary requirements and application is received by Us.

Adding New Dependents We require payment of any required Premiums and an enrollment on our enrollment form to add a new Dependent. Monthly Premiums must be paid from the date coverage starts. You must check with your group contractholder to determine if you are responsible for all or a portion of these Premiums. This section outlines the time periods for enrollment and the date coverage starts.

Special Enrollment Periods Special Enrollment Periods are periods when an eligible Group Member or Dependent may enroll in the vision plan under certain circumstances after they were first eligible for coverage. The eligible circumstances are: 1) a loss of other group vision plan coverage; 2) loss of Medical Assistance (Medicaid) or Children's Health Insurance Program (CHIP) coverage; 3) eligibility for Premium assistance under Medicaid or CHIP; 4) acquiring a new Dependent; or 5) adding a dependent under age three (3). The request for enrollment must be within 30 days (unless otherwise noted) of the eligible circumstance. Unless otherwise specified, coverage will be made effective in accordance with applicable regulatory requirements.

Newborns, newborn grandchildren, and children placed for adoption or foster care, and Dependents acquired through a child support order or other court order, are eligible immediately from the moment of birth, adoption or placement for adoption or foster care, or the date of the court order, as the case may be - see "Eligible Dependents" in the "Eligibility" section.

1. Loss of Group Health Plan Coverage

Group Members or Dependents who are eligible but not enrolled in the vision plan may enroll for coverage in the vision plan as special enrollees upon a loss of other vision plan coverage if all of the following conditions are met:

a. the Group Member or Dependent was covered under a group vision plan or other vision insurance coverage at the time coverage was previously offered to the Group Member or Dependent;

b. the Group Member must complete any required written waiver of coverage and state in writing that, at such time, other vision insurance coverage was the reason for declining enrollment;

c. the Group Member's or Dependent's coverage is terminated because: his/her COBRA continuation has been exhausted (not due to failure to pay Premium or for cause), he/she is no longer eligible for the plan due to a divorce or legal separation, death of the Employee, termination of employment, reduction in hours cessation of Dependent status, all employer contributions towards the coverage were terminated, the individual no longer lives or works in the service area; and,

d. the Group Member or Dependent requests enrollment not later than 30 days after the termination of coverage or employer contribution.

Coverage for Group Members or Dependents (other than newborns, newborn grandchildren and children placed for adoption or foster care, or Dependents acquired through a child support order or other court order - see "Eligibility" section) who are eligible to enroll in the Plan under the special Enrollment Periods provision will be effective the day after the termination of prior coverage.

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2. Loss of Medical Assistance (Medicaid) or Children's Health Insurance Program (CHIP) Coverage

Group Members or Dependents who are eligible but not enrolled in the vision plan may enroll for coverage in the vision plan as special enrollees upon the loss of Medicaid or CHIP coverage if all the following conditions are met: a. the Group Member or Dependent was covered under Medicaid or CHIP at the time coverage was

previously offered to the Group Member or Dependent;

b. the Group Member must complete any required written waiver of coverage and state in writing that, at such time, Medicaid or CHIP coverage was the reason for declining enrollment; and,

c. the Group Member or Dependent must request enrollment no later than 60 days after the termination of Medicaid or CHIP coverage.

3. Eligibility for Premium Assistance

Group Members or Dependents who are eligible, but not enrolled in the vision plan, may enroll for coverage in the vision plan as special enrollees upon becoming eligible for Premium assistance through the Medical Assistance (Medicaid) or Children's Health Insurance Program (CHIP) if all the following conditions are met: a. the employer must submit any required documentation indicating that the Group Member and/or

Dependents are eligible for Premium assistance through Medicaid or CHIP; and,

b. the Group Member or Dependent must request enrollment no later than 60 days after becoming eligible for Premium assistance through Medicaid or CHIP.

4. Acquiring a New Dependent

Eligible Group Members who are either enrolled or not enrolled in the vision plan may enroll themselves and eligible dependents in the vision plan as special enrollees when the eligible Group Member experiences a marriage, birth, adoption, or placement for adoption or foster care, or there is a Dependent for whom coverage is required or permitted through a child support order or other court order. These events provide the eligible Group Member, Spouse or child(ren) the opportunity to apply for coverage under the vision plan during special Enrollment Periods.

Coverage for such Group Members or Dependents who are eligible to enroll in the Plan under the special Enrollment Periods provision may be added effective on the date of marriage, birth, adoption or placement for adoption or foster care, or the date of the court order, as the case may be. The Group Member or Dependent must request enrollment no later than 30 days after the event. If we receive the enrollment form to add your adopted or foster child requesting an Effective Date later than the date of adoption or foster care placement, the child must meet the requirements of the special enrollment period.

If coverage is sought pursuant to a child support order or other order to provide coverage, coverage may be effective as of the date of the court order.

5. Adding a Dependent Under Age Three (3)

Children may be added to the Plan at the time the eligible Employee originally becomes effective or may be added anytime up to 30 days following the child’s 3rd birthday. If a child is born or adopted after the employee’s original Effective Date, such child may be added anytime between birth (or date of adoption) and 30 days following the child’s 3rd birthday. In the event that the child is not added by 30 days following his or her 3rd birthday, that child may be added only if there is a special Enrollment Period or at the next open Enrollment period, if any.

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Adding Disabled Dependents Disabled Dependents who are not currently covered under this Benefit Booklet, may be added as long as they otherwise meet the definition of Dependent. Coverage starts on the first day of the month following our receipt of the enrollment form and monthly Premium.

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CONTRACT TERM AND RENEWAL If coverage is terminated for all Group Members in your Plan, we will give all Group Members a 30-day notice of termination prior to the Effective Date of cancellation using a list of addresses which is updated every 12 months. We will not give this notification if we have reasonable evidence to indicate that this coverage will be replaced by a similar policy, plan, or contract. Coverage ends on the earliest of the following dates: 1. The last day of the contract month that required Premiums are paid for your coverage if we do not

receive payment when due. Your payment of Premiums to the group contractholder does not guarantee coverage unless we receive full payment when due.

2. For all Group Members and Dependents, the last day of the contract month the Group Member is no longer eligible as defined in the group contractholder's contract with us.

3. The last day of the contract month the Group Member or Dependent enters military service for duty lasting more than 31 days.

4. For Dependents, the date the Dependent is no longer eligible for coverage. This is the last day of the contract month that:

a. The Group Member and Spouse divorce or legally separate, for the ex-spouse and any covered stepchildren.

b. The Dependent child reaches the Dependent Limiting Age except where a child may be classified as a disabled Dependent, in which case coverage may be continued if you submit payment of all required Premiums and written application within 31 days after your Dependent becomes disabled. If we do not receive payment of required Premiums and written application within 31 days after the date of becoming disabled, coverage starts on the first day of the contract month after we receive the enrollment form.

c. The Dependent grandchild is no longer eligible.

d. The disabled Dependent is no longer eligible.

e. An individual no longer meets the domestic partner requirements noted in the "Eligible Dependents" section, for the domestic partner and any covered children of the domestic partner.

5. The last day of the month that the Group Member requests that coverage be terminated.

6. The date we determine a Group Member or Dependent committed fraud or misrepresentation with respect to eligibility or any other material fact subject to the time limits outlined in the "Time Limit for Misstatements" section.

You must provide notification to your group contractholder within 60 days of changes in your or your Dependent's eligibility to obtain your continuation of coverage options. Refer to the "Continuation of Coverage" section of this Benefit Booklet for information regarding extension of coverage, or how to obtain an individual qualified plan.

Benefits After Coverage Terminates

We are not liable to pay any benefits for Covered Services which are started after a Covered Person’s Termination Date. However, coverage for completion of a vision procedure requiring two (2) or more visits on separate days will be extended for a period of 90 days after the Termination Date in order for the procedure to be finished. The procedure must be started prior to the Termination Date.

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CONTINUATION OF COVERAGE You or your covered Dependents may continue this coverage if coverage ends due to one of the qualifying events listed below. You and your eligible Dependents must be covered on the day before the qualifying event in order to continue coverage.

NOTE: You may have a right to Special Enrollment in a new plan if you have coverage under this plan. See "Eligibility" section. Note that your notice obligations are different for Special Enrollment.

Qualifying Events

If you are the Group Member and are covered, you have the right to elect continuation coverage if you lose coverage because of any one (1) of the following qualifying events:

• Voluntary or involuntary termination of your employment (for reasons other than gross misconduct).

• Reduction in the hours of your employment (lay-off, leave of absence, strike, lockout, change from full-time to part-time employment).

• Total disability - Total disability means the Group Member's inability to engage in or perform the duties of the Group Member's regular occupation or employment within the first two (2) years of disability. After the first two (2) years, it means the Group Member's inability to perform any occupation for which the Group Member is educated or trained.

If you are the Spouse/ex-spouse of a covered Group Member, you have the right to elect continuation coverage if you lose coverage because of any of the following qualifying events:

• The death of the Group Member.

• A termination of the Group Member's employment (as described above) or reduction in the Group Member's hours of employment with the employer.

• Entering of decree or judgment of divorce or legal separation from the Group Member when Spouse/ex-spouse was covered on the day before the entry of the valid degree of dissolution of marriage. (This includes if the Group Member terminates your coverage in anticipation of the divorce or legal separation. A later divorce or legal separation is considered a qualifying event even though you lost coverage earlier. You must notify the administrator within 60 days after the later divorce or legal separation and establish that your coverage was terminated in anticipation of the divorce or legal separation. Continuation coverage may be available for the period after the divorce or legal separation.)

• The Group Member becomes enrolled in Medicare.

• The Group Member becomes totally disabled (as defined above).

A Dependent child of a covered Group Member has the right to elect continuation coverage if he or she loses coverage because of any of the following qualifying events:

• The death of the Group Member.

• The termination of the Group Member's employment (as described above) or reduction in the Group Member's hours of employment with the employer.

• Parents' divorce or legal separation.

• The Group Member becomes enrolled in Medicare.

• The Dependent ceases to be a "Dependent child" under this group contract.

• The total disability of the Group Member (as defined above).

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Your Notice Obligations

You and your Dependents must notify the group contractholder of any of the following events within 60 days of the occurrence of the event:

• divorce or legal separation; or,

• a Dependent child no longer meets the group contract's eligibility requirements.

If you or your Dependents do not provide this required notice, any Dependent who loses coverage is NOT eligible to elect continuation coverage. Furthermore, if you or your Dependents do not provide this required notice, you or your Dependent must reimburse any claims mistakenly paid for expenses incurred after the date coverage actually terminates.

Note: Disability Extensions also require specific notice. See below for these notification requirements.

When you notify the group contractholder of a divorce, legal separation, or a loss of Dependent status, the group contractholder will notify the affected family member(s) of the right to elect continuation coverage. If you notify the group contractholder of a qualifying event or disability determination and the group contractholder determines that there is no extension available, the group contractholder will provide an explanation as to why you or your Dependents are not entitled to elect continuation coverage.

Group Contractholder's and Plan Administrator's Notice Obligations

The group contractholder has 30 days to notify the plan administrator of events they know have occurred, such as termination of employment or death of the Group Member. This notice to the plan administrator does not occur when the plan administrator is the group contractholder. After plan administrators are notified of the qualifying event, they have 14 days to send the qualifying event notice. Qualified beneficiaries have 60 days to elect continuation coverage. The 60-day time frame begins on the date coverage ends due to the qualifying event or the date of the qualifying-event notice, whichever is later.

The group contractholder will also notify you and your Dependents of the right to elect continuation coverage after receiving notice that one of the following events occurred and resulted in a loss of coverage: the Group Member's termination of employment (other than for gross misconduct), reduction in hours, death, or the Group Member's becoming enrolled in Medicare.

Election Procedures

You and your Dependents must elect continuation coverage within 60 days after coverage ends, or, if later, 60 days after the plan administrator provides you or your family member with notice of the right to elect continuation coverage. If you or your dependents do not elect continuation coverage within this 60-day election period, you will lose your right to elect continuation coverage. If your qualifying event is the death of the Employee, then you will be given a grace period of 90 days from the date you receive notice of the Premium requirement.

You or your dependent Spouse may elect continuation coverage for all qualifying family members; however, each qualified beneficiary is entitled to an independent right to elect continuation coverage. Therefore, a Spouse/ex-spouse may not decline coverage for the other Spouse/ex-spouse and a parent cannot decline coverage for a non-minor dependent child who is eligible to continue coverage. In addition, a Dependent may elect continuation coverage even if the covered Group Member does not elect continuation coverage.

You and your Dependents may elect continuation coverage even if covered under another employer-sponsored group vision plan or enrolled in Medicare.

How to Elect

Contact the group contractholder to determine how to elect continuation coverage.

Type of Coverage

Generally, continuation coverage is the same coverage that you or your Dependent had on the day before the qualifying event. Anyone who is not covered under the group contract on the day before the qualifying event is generally not entitled to continuation coverage. Exceptions include: 1) when coverage

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was eliminated in anticipation of a divorce or legal separation, the later divorce or legal separation is considered a qualifying event even though the ex-spouse/Spouse lost coverage earlier; and, 2) a child born to or placed for adoption with the covered Group Member during the period of continuation of coverage may be added to the coverage for the duration of the qualified beneficiary's maximum continuation period.

Qualified beneficiaries are provided the same rights and benefits as similarly-situated beneficiaries for whom no qualified event has occurred. If coverage is modified for similarly-situated active employees or their Dependents, then continuation coverage will be modified in the same way. Examples include: 1) if the group offers an open Enrollment Period that allows active employees to switch between plans, all qualified beneficiaries on continuation are allowed to switch plans as well; and, 2) if active employees are allowed to add new Spouses to coverage if the enrollment for coverage is received within 30 days of the marriage, qualified beneficiaries who get married while on continuation are afforded this same right.

Maximum Coverage Periods

Continuation coverage terminates before the maximum coverage period in certain situations described later under the heading "Termination of Continuation Coverage Before the End of the Maximum Coverage Period." In other instances, the maximum coverage period can be extended as described under the heading "Extension of Maximum Coverage Periods."

18 Months. If you or your Dependent loses coverage due to the Group Member's termination of employment (other than for gross misconduct) or reduction in hours, then the maximum continuation coverage period is 18 months from the first of the month following termination or reduction in hours.

36 Months. If a Dependent loses coverage because the Group Member became enrolled in Medicare or because of a loss of Dependent status under the group contract, then the maximum coverage period (for Spouse and dependent child) is three (3) years from the date of the qualifying event.

Under Minnesota Law. If you or your Dependents lose coverage because of the Group Member's total disability (as defined above), then the maximum coverage period is the earlier of the date total disability ends or the date coverage would otherwise end. If a Dependent loses group vision coverage because of the Group Member's death, divorce or legal separation, then the maximum coverage period (for ex-spouse/Spouse and dependent child) is the earlier of Dependent’s enrollment date in other group coverage or the date coverage would otherwise end.

Continuation Premiums

Premiums for continuation can be up to the group rate plus a two (2) percent administration fee. In the event of a dependent's disability, the Premiums for continuation for the Employee and dependents can be up to 150% of the group rate for months 19-29 if the disabled dependent is covered. If the qualifying event for continuation is the Group Member's total disability, the administration fee is not permitted. All Premiums are paid directly to the group contractholder.

Extension of Maximum Coverage Periods

Maximum coverage periods of 18 or 36 months can be extended in certain circumstances.

• Disability Extension: This extension is applicable when the qualifying event is the Group Member's termination of employment or reduction of hours, and the extension applies to all qualified beneficiaries. If your Dependent who is a qualified beneficiary is determined by the Social Security Administration (SSA) to be disabled at any time during the first 60 days of continuation, then the continuation period for all qualified beneficiaries is extended to 29 months from the date coverage terminated.

Notice Obligation: For the 29-month continuation coverage period to apply, a qualified beneficiary must notify the plan administrator of the SSA disability within 60 days after the latest of: 1) the date of the Social Security disability determination; 2) the date of the Group Member's termination of employment or reduction of hours; 3) the date on which the qualified beneficiary loses (or would lose) coverage under the group contract as a result of the qualifying event; and, 4) the date on which the qualified beneficiary is informed, either through the Benefit Booklet or the initial COBRA notice, of

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both the responsibility to provide the notice of disability determination and the plan's procedures for providing such notice to the administrator.

Notice Obligation: The qualified beneficiary must notify the plan administrator of the Social Security disability determination before the end of the 18-month period following the qualifying event (the Group Member's termination of employment or reduction of hours).

Notice Obligation: If during the 29-month extension period there is a "final determination" that a qualified beneficiary is no longer disabled, the qualified beneficiary must notify the plan administrator within 30 days after the date of this determination. This extension coverage ends for all qualified beneficiaries on the extension as of: 1) the first day of the month following 30 days after a final determination by the SSA that the formerly disabled qualified beneficiary is no longer disabled; or, 2) the end of the coverage period that applies without regard to the disability extension.

• Multiple Qualifying Events: This extension is applicable when the initial qualifying event is the Group Member's termination of employment or reduction of hours and is followed, within the original 18-month period (or 29-month period if there has been a disability extension), by a second qualifying event that has a 36-month or an indefinite maximum coverage period. The extension applies to the Group Member's Dependents who are qualified beneficiaries.

When a second qualifying event occurs that gives rise to a 36-month maximum coverage period for the Dependent, the maximum coverage period (for the Dependent) becomes three (3) years from the date of the initial termination or reduction in hours. For the 36-month maximum coverage period to apply, notice of the second qualifying event must be provided to the plan administrator within 60 days after the date of the event. If no notice is given within the required 60-day period, no extension coverage will occur.

When a second qualifying event occurs that gives rise to an indefinite maximum coverage period for the Dependent, then the maximum coverage period (for the Dependent) becomes indefinite. For an indefinite maximum coverage period to apply, notice of the second qualifying event must be provided to the plan administrator within 60 days after the date of the event. If no notice is given, no extension of continuation coverage will occur.

• Pre-Termination or Pre-Reduction Medicare Enrollment: This extension applies when the qualifying event is the reduction of hours or termination of employment that occurs within 18 months after the date of the Group Member's Medicare enrollment. The extension applies to the Group Member's Dependents who are qualified beneficiaries.

If the qualifying event occurs within 18 months after the Group Member becomes enrolled in Medicare, regardless of whether the Group Member's Medicare enrollment is a qualifying event (causing a loss of coverage under the group contract), the maximum period of continuation for the Group Member's Dependents who are qualified beneficiaries is three (3) years from the date the Group Member became enrolled in Medicare. (Example: Group Member becomes enrolled in Medicare on January 1. Group Member's termination of employment is May 15. The Group Member is entitled to 18 months of continuation from the date coverage is lost. The Group Member's Dependents are entitled to 36 months of continuation from the date the Group Member is enrolled in Medicare.)

If the qualifying event is more than 18 months after Medicare enrollment, is the same day as the Medicare enrollment, or occurs before Medicare enrollment, no extension is available.

• Group Contractholder's Bankruptcy: The bankruptcy rule, technically, is an initial qualifying event rather than an extending rule. However, because it would result in a much longer maximum coverage period than 18 or 36 months, we include it here. If the group contractholder files Chapter 11 bankruptcy, it may trigger COBRA coverage for certain retirees and their related qualified beneficiaries. A retiree is entitled to coverage for life. The retiree's Spouse and Dependent children are entitled to coverage for the life of the retiree, and, if they survive the retiree, for 36 months after the retiree's death. If the retiree is not living when the qualifying event occurs, but the retiree's Spouse is covered by the group contract, then that surviving Spouse is entitled to coverage for life.

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Termination of Continuation Coverage Before the End of Maximum Coverage Period

Continuation coverage of the Group Member and Dependents will automatically terminate when any one of the following events occur:

• The group contractholder no longer provides group vision coverage to any of its employees.

• The Premium for the qualified beneficiary's continuation coverage is not paid when due.

• If during a 29-month maximum coverage period due to disability the SSA makes the final determination that the qualified beneficiary is no longer disabled.

• Occurrence of any event (e.g., submission of fraudulent benefit claims) that permits termination of coverage for cause with respect to any covered Group Members or their Dependents whether or not they are on continuation coverage.

• Voluntarily canceling your continuation coverage.

When termination takes effect earlier than the end of the maximum period of continuation coverage, a notice will be sent from the plan administrator. The notice will contain the reason continuation coverage has been terminated, the date of the termination, and any rights to elect alternative coverage that may be available.

Children Born to or Placed for Adoption With the Covered Group Member During Continuation Period

A child born to, adopted by or placed for adoption with a covered Group Member during a period of continuation coverage is considered to be a qualified beneficiary provided that the covered Group Member is a qualified beneficiary and has elected continuation coverage for himself/herself. The child's continuation coverage begins on the date of birth, adoption or placement for adoption as outlined in the "Eligibility" section, and it lasts for as long as continuation coverage lasts for other family members of the Group Member.

Open Enrollment Rights and Special Enrollment Rights

Qualified beneficiaries who have elected continuation will be given the same opportunity available to similarly-situated active employees to change their coverage options or to add or eliminate coverage for Dependents at open enrollment. Special enrollment rights apply to those who have elected continuation. Except for certain children described above, Dependents who are enrolled in a special Enrollment Period or open Enrollment Period do not become qualified beneficiaries – their coverage will end at the same time that coverage ends for the person who elected continuation and later added them as Dependents.

Address Changes, Marital Status Changes, Dependent Status Changes and Disability Status Changes

If your or your Dependent's address changes, you must notify the plan administrator in writing so the plan administrator may mail you or your Dependent important continuation notices and other information. Also, if your marital status changes or if a Dependent ceases to be a Dependent eligible for coverage under the terms of the group contract, you or your Dependent must notify the plan administrator in writing. In addition, you must notify the plan administrator if a disabled Group Member or family member is no longer disabled.

Uniformed Services Employment and Reemployment Rights Act (USERRA)

If you are called to active duty in the uniformed services, you may elect to continue coverage for you and your eligible Dependents under USERRA. This continuation right runs concurrently with your continuation right under COBRA and allows you to extend an 18-month continuation period to 24 months. You and your eligible Dependents qualify for this extension if you are called into active or reserve duty, whether voluntary or involuntary, in the Armed Forces, the Army National Guard, the Air National Guard, full-time National Guard duty (under a federal, not a state, call-up), the commissioned corps of the Public Health Services and any other category of persons designated by the President of the United States.

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Questions

If you have general questions about continuation of coverage, please call the telephone number on the back of your identification card for assistance.

Overview The following chart is an overview of the information outlined in the previous sections. For more details, refer to the previous sections.

Qualifying Event/Extension Who May Continue Maximum Continuation Period

Employment ends (for reasons other than gross misconduct)

Reduction in hours of employment (lay-off, leave of absence, strike, lockout, change from full-time to part-time employment)

Group Member and dependents

Earlier of: 1. 18 months, or 2. Enrollment date in other

group coverage.

Divorce or legal separation Ex-spouse/Spouse and any dependent children that lose coverage

Earlier of: 1. Enrollment date in other

group coverage, or 2. Date coverage would

otherwise end.

Death of Group Member Surviving Spouse and dependent children

Earlier of: 1. Enrollment date in other

group coverage, or 2. Date coverage would

otherwise end if the Group Member had lived.

Dependent child loses eligibility Dependent child Earliest of: 1. 36 months, or 2. Enrollment date in other

group coverage, or 3. Date coverage would

otherwise end.

Dependents lose eligibility due to the Group Member's enrollment in Medicare

All dependents Earliest of: 1. 36 months, or 2. Enrollment date in other

group coverage, or 3. Date coverage would

otherwise end.

Retirees of the group contractholder filing Chapter 11 bankruptcy (includes substantial reduction in coverage within one (1) year of filing)

Retiree Lifetime continuation.

Dependents Lifetime continuation until the retiree dies, then an additional 36 months following retiree's death.

Total disability of Group Member Group Member and dependents Earlier of: 1. Date total disability ends,

or 2. Date coverage would

otherwise end.

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Qualifying Event/Extension Who May Continue Maximum Continuation Period

Extensions to 18-month maximum continuation period:

Total disability of dependent(s)

Disabled dependent and all other covered family members

Earliest of:

1. 29 months after the Group Member leaves employment, or

2. Date total disability ends, or

3. Date coverage would otherwise end.

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REIMBURSEMENT AND SUBROGATION If we pay benefits for expenses you incur as a result of any act of any person, and you later obtain full compensation, you are obligated to reimburse us for the benefits paid. If you or your dependents receive benefits under this Plan arising out of an illness or injury for which a responsible party is or may be liable, we are also entitled to subrogate against any person, corporation and/or other legal entity, or any insurance coverage, including both first- and third-party automobile coverages to the extent we provided any benefits. Our right to reimbursement and subrogation is subject to you obtaining full recovery, as explained in Minnesota statutes 62A.095 and 62A.096. Unless we are separately represented by our own attorney, our right to reimbursement and subrogation is subject to reduction for first, our pro rata share of costs, disbursements, and then reduced by reasonable attorney fees incurred in obtaining the recovery. For the purposes of this section, full recovery does not include payments made by a health plan to or for the benefit of a covered person. If Blue Cross is separately represented by an attorney, Blue Cross and the covered member, by their attorneys, may enter into an agreement regarding allocation of the covered member's costs, disbursements, and reasonable attorney fees and other expenses. If Blue Cross and the covered member cannot reach agreement on allocation, Blue Cross and the covered member shall submit the matter to binding arbitration.

Notice Requirement You must provide timely written notice to us of the pending or potential claim if you make a claim against a third party for damages that include repayment for expenses incurred for your benefit. We may take appropriate action to preserve our rights under this Reimbursement and Subrogation section, including our right to intervene in any lawsuit you have commenced.

Duty to Cooperate You must cooperate with Blue Cross in assisting it to protect its legal rights under this provision. You agree that the limited period in which we may seek reimbursement or to subrogate does not commence to run until you or your attorney has given notice to us of your claim against a third party.

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GENERAL PROVISIONS

Release of Records You agree to allow all health care providers and Vision Care Providers to give us needed information about the care they provide to you. We may need this information to process claims, conduct utilization review, care management and quality improvement activities, reimbursement and subrogation, and for other vision plan activities as permitted by law. We keep this information confidential, but we may release it if you authorize release, or if state or federal law permits or requires release without your authorization. If a provider requires special authorization for release of records, you agree to provide this authorization. Your failure to provide authorization or requested information may result in denial of your claim.

Entire Contract This Benefit Booklet and the group contract issued to the group contractholder make up the entire contract of coverage. The master group contract is available for your inspection at your group contractholder's office. Your group contractholder is the Plan Administrator for your coverage plan. We have discretionary authority to determine your eligibility for benefits and to construe the provisions of the group contract and this Benefit Booklet. All statements made by the creditor, employer, trustee, or any executive officer or trustee on behalf of the group to be insured, shall, in the absence of fraud, be deemed representations and not warranties, and that no such statement shall be used in defense to a claim under the contract, unless it is contained in the written enrollment form. This Benefit Booklet is issued and delivered in the state of Minnesota. It is subject to the substantive laws of the state of Minnesota, without regard to its choice of law principles; and, it is not subject to the substantive laws of any other state. This Benefit Booklet describes Your Blue Cross vision coverage. It replaces all other vision benefit booklets You have received from Us. This Benefit Booklet explains the eligibility, Covered Services, and Benefit Booklet terms of coverage. It is important that You read this entire Benefit Booklet carefully. If You have questions about Your coverage, please contact Us at the address or telephone numbers listed on the "Customer Service" page. Blue Cross is the insurer. This Benefit Booklet is a fully insured vision Benefit Booklet designed solely to provide vision care. Coverage is subject to all terms and conditions of this Benefit Booklet, including Vision Necessity. All changes to the Benefit Booklet must be approved by Us. No agent may change this Benefit Booklet or waive any of its provisions.

Time Limit for Misstatements If there is any misstatement in the written enrollment form that the group contractholder completes, we cannot use the misstatement to cancel coverage that has been in effect for, or deny a claim incurred on a date that is on or after, two (2) years or more from the initial date of coverage issued as a result of that enrollment form. This time limit does not apply to fraudulent misstatements.

Indemnity for Loss of Life In the event of loss of life, if you used an Non-Participating Vision Care Provider, we will pay for Covered Services in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to your estate. Any other outstanding payments for Covered Services unpaid at the time of your death may, at your option, be paid either to such beneficiary or to such estate. All other payments for Covered Services will be payable to you.

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Change of Beneficiary Unless you make an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to you. The consent of the beneficiary is not required to surrender or assign benefits under this Benefit Booklet or to change the beneficiary or make other changes in this Benefit Booklet.

Changes to the Contract The group contractholder reserves the power at any time and from time to time (and retroactively, if necessary or appropriate to meet the requirements of the code or ERISA) to modify or amend, in whole or in part, any or all provisions of the Plan, provided, however that no modification or amendment shall divest an Employee of a right to those benefits to which he or she has become entitled under the Plan. Blue Cross will communicate any adopted changes to the group contractholder. All changes to the group contract must be approved by one (1) of our executive officers and attached to the group contract with the group contractholder. No agent can legally change the group contract or waive any of its terms.

Assignment Blue Cross may assign this contract and its rights and obligations hereunder.

Conformity with State Laws Any part of the contract in conflict with the laws of the state where the Group Member lives on the contract’s Effective Date is changed to conform to the minimum requirements of that state’s law. After the Effective Date, the contract may be amended without mutual agreement of the parties. Such amendment will not affect a claim incurred prior to the Effective Date of the change.

Legal Actions No action at law or in equity shall be brought to recover under this Benefit Booklet prior to the expiration of 60 days after written proof of loss has been filed in accordance with the requirements of this Benefit Booklet. No such action shall be brought after the expiration of three (3) years after the time written proof of loss is required to be furnished.

No Third-Party Beneficiaries The benefits described in this plan are intended solely for the benefit of you and your covered dependents. No one else may claim to be an intended or third-party beneficiary of this plan. No one other than you or your dependents may bring a lawsuit, claim or any other cause of action related in any way to this plan, and you may not assign such rights to any other person.

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Prior Approval Blue Cross reviews all services to verify that they are medically necessary and that the treatment provided is the proper level of care. All applicable terms and conditions of your Plan including Exclusions, Deductible, copay, and Coinsurance provisions continue to apply with an approved prior authorization. Prior authorization is a process that involves a benefits review and determination of medical necessity before a service is rendered. Prior authorization for visually required contact lenses and comprehensive low vision evaluations, subsequent follow-up visits following such evaluation or low vision aids is required. Participating Vision Care Providers are required to obtain prior authorization for you. You are required to obtain prior authorization when you use Non-Participating Vision Care Providers in Minnesota and any Non-Participating Vision Care Provider outside of Minnesota. Some of these Non-Participating Vision Care Providers may obtain prior authorization for you. Verify with your Non-Participating Vision Care Providers if this is a service they will perform for you or not.

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CLAIM PROVISIONS

Notice of Claim Written notice of claim must be given to Blue Cross within 20 days after the occurrence or commencement of any loss covered by the Benefit Booklet, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the Covered Person to Blue Cross, with information sufficient to identify the Covered Person, shall be deemed notice to Blue Cross.

Claim Forms Upon receipt of a notice of claim, We will furnish to the Covered Person such forms as are usually furnished by Us for filing proof of loss. If such forms are not furnished before the expiration of 15 days after We received notice of any claim under the Benefit Booklet, the person making such claim shall be deemed to have complied with the requirements of the Benefit Booklet as to proof of loss upon submitting within the time fixed in the Benefit Booklet for filing proof of loss, written proof covering the occurrence, character, and extent of the loss for which claim is made.

Proof of Loss Written proof of loss must be furnished to Us at Our office within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one (1) year from the time proof is otherwise required. Our acknowledgment of the receipt of notice given or the furnishing of forms for filing proofs of loss, or the acceptance of such proofs, or the investigation of any claim thereunder shall not operate as a waiver of any of the rights of Blue Cross in defense of any claim arising under such Benefit Booklet.

Time Payment of Claims All benefits payable under this Benefit Booklet for any loss will be paid immediately after receipt of due written proof of such loss.

Payment of Claims All benefits under this Benefit Booklet shall be payable to the Participating Vision Care Provider or the Covered Person, or to the Covered Person, except that if the Covered Person is a minor or otherwise not competent to give a valid release, such benefits may be made payable to the custodial parent, guardian, or other person actually providing support. At the option of Blue Cross and unless the Covered Person requests otherwise in writing not later than the time of filing proofs of such loss, all or a portion of any indemnities provided by this Benefit Booklet on account of vision services may, be paid directly to the Participating Vision Care Provider office rendering such services. Blue Cross does not pay claims to providers or to members for services received in countries that are sanctioned by the United States Department of Treasury’s Office of Foreign Assets Control (OFAC). Countries currently sanctioned by OFAC include Cuba, Iran, and Syria. OFAC may add or remove countries from time to time.

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Physical Examinations We have the right to ask you to be examined by a Vision Care Provider during the review of any claim. We choose the Vision Care Provider and pay for the exam whenever we request this. We also have the right to make an autopsy in case of death where it is not forbidden by law. Failure to comply with this request may result in denial of your claim.

Review of a Benefit Determination

If you are not satisfied with a benefit determination or payment, please contact our Customer Service Department at the toll-free telephone number on the front of this Benefit Booklet or on your ID card. We will try to resolve your oral complaint as quickly as possible. However, if after speaking with a Customer Service representative, our resolution of your oral complaint is wholly or partially adverse to you or not resolved to your satisfaction, within ten (10) days of our receipt of your oral complaint, you may submit an Appeal in writing. We will provide you a Complaint form on which you can include all the necessary information to file your Appeal. If you need assistance, we will complete the written Complaint form and mail it to you for your signature. You must tell us all reasons and arguments in support of your Appeal, and you must identify and provide all evidence in support of your Appeal unless that evidence is already in our possession. Refer to the “Appeal Process” below. Contact us further steps you can take regarding your claim.

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APPEAL PROCESS

Appeal Procedures The following Definitions apply to the Appeal Process. Adverse Benefit Determination means a decision relating to a vision care service or claim that is partially or wholly adverse to the complainant. Appeal means any grievance that is not the subject of litigation concerning any aspect of the provision of services under your Benefit Booklet. If the Appeal is from an applicant, the Appeal must relate to the application. If the Appeal is from a formerly Covered Person, the Appeal must relate to the provision of services during the period of time the Covered Person was enrolled in the Plan. If we decide a claim that is wholly or partially adverse to you, and you wish to Appeal, you are required to submit an Appeal. You have 180 days from the date you received notice of the Adverse Benefit Determination to Appeal the decision. You or anyone you authorize to act on your behalf may submit your Appeal in writing, or you may request an Complaint form. We will send a Complaint form to you upon request. The request for an Appeal should include;

a) The Covered Person’s name, identification number, and group number b) The pre-service claim or post-service claim for which coverage was denied c) A copy of the denial d) The reason why you or your Vision Care Professional believes the service should be covered e) Any available medical information you believe will be helpful to the decision f) Your Appeal must state all reasons and arguments in support of the Appeal, and you must submit

all evidence in support of your Appeal, unless that evidence is already in our possession.

Send your Appeal to:

Vision Care Processing Unit P.O. Box 1525 Latham, NY 12110

In addition, you may file your Appeal with the Minnesota Commissioner of Commerce at any time by calling (651) 539-1600 or toll-free 1-800-657-3602. When a medically necessary determination is necessary to resolve your Appeal, we will process your Appeal using utilization review Appeal procedures. Utilization review applies a well-defined process to determine whether vision care services are medically necessary and eligible for coverage. The decision on this Appeal will be made by a Vision Care Professional who did not make the initial determination. Utilization review applies only when the service requested is otherwise covered under this vision plan. In order to conduct utilization review, we will need specific information. If you or your attending vision care professional do not release necessary information, approval of the requested service, procedure, or admission to a facility may be denied.

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Expedited Appeal When a prior authorization decision is wholly or partially adverse to you and your attending vision care professional believes that an expedited Appeal is warranted, you and your attending health care professional may request an expedited Appeal. You and your attending health care professional may Appeal the determination over the telephone. Our Appeal staff will include the consulting Vision Care Provider if reasonably available. When an expedited Appeal is completed, we will notify you and your attending health care professional of the decision as expeditiously as the enrollee's medical condition requires, but no later than 72 hours from our receipt of the expedited Appeal request.

Standard Appeal We will notify you that we have received your written Appeal. We will inform you of our decision and the reasons for the decision within 30 days of receiving your Appeal and all necessary information. If we are unable to make a decision within 30 days due to circumstances outside Our control, we may take up to 14 additional days to make a decision. If we take more than 30 days to make a decision, We will inform you of the reasons for the extension. If we need specific information, including medical records, to complete Our review and you or your health care professional does not release the requested information. Your claim may be denied. You have the right to review the information that we relied on in the course of the Appeal.

External Review You must exhaust your internal Appeals option prior to requesting External Review unless: 1) Blue Cross waives the exhaustion requirement in writing; 2) Blue Cross substantially fails to comply with required procedures; or, 3) you qualified for and applied for an Expedited First Level Appeal of a medical determination and applied for an Expedited External Review at the same time. If your Appeal concerns a complaint decision relative to a service or claim and you believe Blue Cross’ Appeal determination is wholly or partially adverse to you, you or anyone you authorize to act on your behalf may submit the Appeal to external review. You must request External Review within six (6) months from the date of the Adverse Benefit Determination. External review of your Appeal will be conducted by an independent organization under contract with the state of Minnesota. The written request must be submitted to the Minnesota Commissioner of Commerce along with a $25 filing fee. You will not be subject to filing fees totaling more than $75 per policy year. The Commissioner may waive the fee in cases of financial hardship. Blue Cross will refund the fee if our determination is reversed by the external reviewer. Minnesota Department of Commerce Attention: Consumer Concerns/Market Assurance Division 85 7th Place East, Suite 500 St. Paul, MN 55101-2198 (651) 539-1600 or toll-free 1-800-657-3602

Expedited External Review Expedited external review will also be provided when a medical condition of which the standard external review time would seriously jeopardize your life or health or jeopardize your ability to regain maximum function. The external review entity must make its expedited determination to uphold or reverse the Adverse Benefit Determination as expeditiously as possible but within no more than 72 hours after receipt of the request for expedited review and notify you and Blue Cross of the determination. If the external review entity's notification is not in writing, the external review entity must provide written confirmation of the determination within 48 hours of the notification.

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Standard External Review The external review entity will notify You and Blue Cross that it has received Your request for external review. Within ten (10) business days of receiving notice from the external review entity, You and Blue Cross must provide the external review entity any information to be considered. Both You and Blue Cross will be able to present a statement of facts and arguments. You may be assisted or represented by any person of Your choice at Your expense. The external review entity will send written notice of its decision to You, Blue Cross, and the Commissioner within 45 days of receiving the request for external review. The external review entity’s decision is binding on Blue Cross, but not binding on You. The Appeals and determination processes described above are subject to change if required or permitted by changes in state or federal law governing Appeal procedures.

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DEFINITIONS Certain terms used throughout this Benefit Booklet begin with capital letters. When these terms are capitalized, they have the meanings set forth below. Allowance - A maximum dollar amount allowed as a benefit for a Covered Service from a Participating Vision Care Provider. The Allowance levels are shown in the "Schedule of Benefits". If the provider's charge is less than the Allowance we will only pay up to the provider's charge. Benefit Booklet - This document, including schedules, addenda and/or endorsements, if any, which are attached to the Benefit Booklet and describe the vision coverage purchased from Blue Cross. Blue Cross – BCBSM, Inc. dba Blue Cross and Blue Shield of Minnesota shown on the front page of this Benefit Booklet, its affiliate or a third party with which Blue Cross contracts for a provider network and/or to perform certain functions to administer the terms of this Benefit Booklet. Also referred to as “We,” “Our,” or “Us.” Coinsurance - Those remaining percentages or dollar amounts of the Maximum Allowable Charge for a Covered Service that are the responsibility of the Covered Person after Blue Cross pays the percentages or dollar amounts shown on the “Schedule of Benefits for a Covered Service.” Copayment - The dollar amount you must pay for certain Covered Services. The "Schedule of Benefits" lists the Copayments and services that require Copayments. Covered Person(s) - The Group Member and Dependents, if any, enrolled under the Group Member’s plan. Also referred to as “You,” “Your,” or “Yourself.” Covered Service(s) – Services shown on the “Schedule of Benefits” for which benefits will be covered subject to the “Schedule of Exclusions.” Deductible(s) -- A specified amount of expenses set forth in the “Schedule of Benefits” for Covered Services that must be paid by the Covered Person before Blue Cross will pay any benefit. Discount – The percentage that a Participating Vision Care Network Provider has agreed to reduce the Covered Person’s charge for the requested service, material or procedure. Discounts are shown in the “Schedule of Benefits.” Discounted vision services, Materials, supplies and treatments described in the “Schedule of Benefits” are not underwritten by us. Effective Date - The date on which the Benefit Booklet begins or the date on which coverage for a Covered Person begins. Enrollment Period – A period of time agreed upon by the Group Member and Us or our authorized representative during which a member may apply for insurance. Eye Examination – An Exam or Eye Examination means services including but not limited to: Case history – chief complaint, eye and vision history, medical history; Entrance distance acuities; External ocular evaluation including slit lamp examination; Internal ocular examination; Tonometry; Distance refraction – objective and subjective; Binocular coordination and ocular motility evaluation; Evaluation of pupillary function; Biomicroscopy; Gross visual fields; Assessment and plan; Advising on matters pertaining to vision care; Form completion – school, motor vehicle, etc.; Dilated Fundus Examination (DFE) (diagnostic procedure used in the detection and management of diabetes, glaucoma, hypertension and other ocular and/or systemic diseases) when professionally indicated. Exclusion(s) – Services, supplies, or charges that are not covered under the Benefit Booklet as stated in the “Schedule of Exclusions.”

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Frequency – The time period shown in the “Schedule of Benefits” during which you are eligible for the Covered Services shown in the “Schedule of Benefits.” This time period is measured from the date of your last Eye Examination or the date you received the eyeglasses, frame or spectacle lenses or contact lenses. Group Member(s) - The individual named on the Certificate who purchased this vision coverage. Unless otherwise indicated, Group Member must be at least 18 years of age. Limitation(s) - The maximum frequency or age limit applied to a Covered Service set forth in the “Schedule of Exclusions.” Limiting Age - The age for a Dependent child defined as when a Dependent child reaches age 26 or the age when a Dependent child is found to no longer be both incapable of self-sustaining employment by reason of mental or physical disability and chiefly dependent upon the Group Member for maintenance and support. Materials – Frames and lenses provided to a Covered Person for ophthalmic correction under the terms and conditions of the Benefit Booklet. Maximum(s) - The greatest amount Blue Cross is obligated to pay for all Covered Services rendered during a specified period as shown on the “Schedule of Benefits.” Maximum Allowable Charge(s) - The greatest amount the Benefit Booklet will allow for a specific service. Non-Participating Vision Care Provider(s) – A Vision Care Provider who has not contracted with Us to limit his/her charges to Covered Persons. Ophthalmologist – A Physician who specializes in the diagnosis, treatment and prescription of medications and lenses related to conditions of the eye, and who may perform Eye Examination and refractive services. Optician – A technician who makes, verifies and delivers lenses, frames and other specially fabricated optical devices and/or contact lenses upon prescription to the intended wearer. Optometrist – A professional provider, licensed where required, who examines, diagnoses, treats and manages diseases, injuries and disorders of the visual system, the eye and associated structures as well as identifies related systemic conditions affecting the eye. Out-of-Pocket Expense(s) – Costs not paid by Us, including but not limited to Coinsurance, Deductibles, amounts billed by Non-Participating Vision Care Providers that are over the Maximum Allowable Charge, costs of services that exceed the Benefit Booklet Limitations or Maximums, or for services that are Exclusions. The Covered Person is responsible to pay for Out-of-Pocket Expenses. Participating Vision Care Provider(s) – A Vision Care Provider who has executed a Participating Vision Care Provider agreement with Us, under which he/she agrees to accept Maximum Allowable Charges as payment in full for Covered Services. Participating Vision Care Providers may also agree to limit their charges for any other services delivered to Covered Persons. Polarized Lenses – Eyeglass lenses that are either green, gray or brown and that redirect the way light enters the lens. Polycarbonate Lenses – Impact resistant and lightweight eyeglass lenses. Premium Anti-Reflective Coating (ARC) – A clear coating placed on eyeglass lenses that limits light reflection by allowing the maximum amount of light to pass through the lens (i.e. Essilor Crizal ™, Carl Zeiss Carat Gold™, etc.)

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Premium Progressive Lenses – All-distance lenses that have no line but progress from distance to intermediate, to near (i.e. Varilux™, etc.) Premium(s) - Payment that must be remitted in exchange for coverage of Covered Persons under the Benefit Booklet. Renewal Date - The date the Benefit Booklet renews. Reimbursement – A flat dollar amount payable under this Benefit Booklet towards a Covered Service from a Non-Participating Vision Care Provider. Reimbursement levels are shown in the “Schedule of Benefits.” If the provider’s charge is less than the Reimbursement we will only pay up to the provider’s charge.

Schedule of Benefits – The summary of Covered Services, Benefit Booklet payments, Deductibles, and Maximums applicable to benefits payable under the Benefit Booklet. Schedule of Exclusions – The list of Exclusions and Limitations applicable to benefits, services, supplies, or charges under the Benefit Booklet. Scratch-Resistant Coating – Coating applied to eyeglass lenses to increase the scratch resistance of the lens surface. Standard Anti-Reflective Coating (ARC) - A clear coating placed on eyeglass lenses that limits light reflection by allowing the maximum amount of light to pass through the lens (i.e. Essilor Reflection Free ™, Carl Zeiss Gold ET™, etc.) Standard Progressive Lenses - All-distance eyeglass lenses that have no line but progress from distance to intermediate, to near (i.e. AO Compact™, Sola VIP™, etc.) Termination Date - The date on which the vision coverage ends for a Covered Person or on which the Benefit Booklet terminates. Tinted Plastic Lenses –

a) Fashion tinting – Eyeglass lenses dyed or coated with pigment of uniform color and density throughout the entire lens.

b) Gradient tinting – Eyeglass lens coating that is darker at the top of the lens, fading to light at the bottom of the lens.

Ultra Anti-Reflective Coating (ARC) - A clear coating placed on eyeglass lenses that limits light reflection by allowing the maximum amount of light to pass through the lens (i.e. Essilor Alize™ with Clear Guard, Carl Zeiss Carat Advantage Gold™, etc.) Ultraviolet Coating – A coating on plastic or glass eyeglass lenses that blocks ultraviolet rays. Vision Care Provider(s) – A person licensed in the state in which vision services are provided. A Vision Care provider will include other duly licensed Ophthalmologist, Optician and Optometrist under the scope of the individual’s license when state law requires independent reimbursement of such practitioners.

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Employee Retirement Income Security Act (ERISA) – Statement of Rights

If you are covered by a contract issued to your employment that is subject to the Employee Retirement Income Security Act of 1974 (ERISA), you are entitled to certain rights and protections. ERISA provides that all Plan participants shall be entitled to:

1. Receive Information About Your Plan and Benefits

a. Examine without charge, at the group contractholder's office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.

b. Obtain, upon written request to the group contractholder, copies of documents governing the

operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Benefit Booklet. The group contractholder may make a reasonable charge for the copies.

c. Receive a summary of the Plan's annual financial report. The group contractholder is required by

law to furnish each participant with a copy of this summary annual report. 2. Continue Group Dental Plan Coverage

Continue dental care coverage for yourself, Spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this Benefit Booklet and the documents governing the Plan on the rules governing your continuation coverage rights.

3. Prudent Actions by Plan Fiduciaries

In addition to creating rights for the Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the Employee benefit plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Claims Processing Purposes:

United Concordia Dental Dental Claims Administrator PO Box 69449 Harrisburg, PA 17106-9449

For all other Purposes:

Blue Cross and Blue Shield of Minnesota 3535 Blue Cross Road Eagan, MN 55122

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4. Enforce Your Rights

If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the group contractholder to provide you the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the group contractholder. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Plan's decision or lack thereof, concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in a federal court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay those costs and fees. If you lose the court may order you to pay these costs and fees, for example, if it finds that your claim is frivolous.

5. Assistance with your Questions

If you have any questions about your Plan, you should contact the group contractholder. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the group contractholder, you should contact the nearest Area Office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N. W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

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Minnesota Life and Health Insurance Guaranty Association Notice

Notice Concerning Policyholder Rights in an Insolvency under Minnesota Life and Health Insurance Guaranty Association Law If the insurer that issued your life, annuity, or health insurance policy becomes impaired or insolvent, you are entitled to compensation for your policy from the assets of that insurer. The amount you recover will depend on the financial condition of the insurer. In addition, residents of Minnesota who purchase life insurance, annuities, or health insurance from insurance companies authorized to do business in Minnesota are protected, subject to limits and exclusions, in the event the insurer becomes financially impaired or insolvent. The protection is provided by the Minnesota Life and Health Insurance Guaranty Association. Minnesota Life and Health Insurance Guaranty Association 4760 White Bear Parkway Suite 101 White Bear Lake, Minnesota 55110 Telephone: (651) 407-3149 Fax: (651) 407-3150 Executive Director: Gerald C. Backhaus The maximum amount the Guaranty Association will pay for all policies on one life by the same insurer is limited to $500,000. Subject to this $500,000 limit, the Guaranty Association will pay up to $500,000 in life insurance death benefits, $130,000 in net cash surrender and net cash withdrawal values for life insurance, $500,000 in health insurance benefits, including any net cash surrender and net cash withdrawal values, $250,000 in annuity net cash surrender and net cash withdrawal values, $410,000 in present value of annuity benefits for annuities in regard to which periodic annuity benefits, for a period of not less than the annuitant’s lifetime or for a period certain of not less than ten years, have begun to be paid on or before the date of impairment or insolvency, or if no coverage limit has been specified for a covered policy or benefit, the coverage limit shall be $500,000 in present value. Unallocated annuity contracts issued to retirement plans, other than defined benefit plans, established under section 401, 403(b), or 457 or the Internal Revenue Code of 1986, as amended through December 31, 1992, are covered up to $250,000 in net cash surrender and net cash withdrawal values, for Minnesota residents covered by the plan provided, however, that the Association shall not be responsible for more than $10,000,000 in claims for all Minnesota residents covered by the plan. If total claims exceed $10,000,000, the $10,000,000 shall be prorated among all claimants. These are the maximum claim amounts. Coverage by the Guaranty Association is also subject to other substantial limitations and exclusions and requires continued residency in Minnesota. If your claim exceeds the Guaranty Association’s limits, you may still recover a part, or all, of that amount from the proceeds of the liquidation of the insolvent insurer, if any exist. Funds to pay claims may not be immediately available. The Guaranty Association assesses insurers licensed to sell life and health insurance in Minnesota after the insolvency occurs. Claims are paid from this assessment. The coverage provided by the Guaranty Association is not a substitute for using care in selecting insurance companies that are well managed and financially stable. In selecting an insurance company or policy you are advised not to rely on coverage by the Guaranty Association. This notice is required by Minnesota state law to advise policyholders of life, annuity or health insurance policies of their rights in the event their insurance carrier becomes financially impaired or insolvent. This notice in no way implies that the company currently has any type of financial problems. All life, annuity and health insurance policies are required to provide this notice.

NOTICE OF PRIVACY PRACTICES

FOR YOUR PROTECTION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) have always been committed to maintaining the security and confidentiality of the information we receive from our members. Whether it's your medical information or other identifiable information (such as your name, address, phone number or member identification number) ("protected health information"), we maintain policies and procedures, and other electronic controls, to guard against unauthorized access and use, and unnecessary collection of information. You should know that we are required by law to provide you this notice about our legal duties and privacy practices. We hope that this notice will clarify our responsibilities to you and provide you with a good understanding of your rights.

Please Note: This notice does not apply to members whose employers are self-insured. If your employer is self-insured, you need to contact your employer for more information about your health plan's privacy practices.

HOW BLUE CROSS SAFEGUARDS YOUR PROTECTED HEALTH INFORMATION Our privacy officer has the overall responsibility to implement and enforce privacy policies and procedures to protect your protected health information. You can be assured that every effort is taken to comply with federal and state laws −physically, electronically and procedurally− to safeguard your information. In some situations, where state laws provide greater protection for your privacy, we will follow the provisions of that state law. Blue Cross requires all of its employees, business associates (such as Prime Therapeutics), providers and vendors to adhere to federal and state privacy laws. Following are descriptions of how your protected health information is handled throughout our administration of your health plan.

Effective November 1, 2017

PERMITTED HANDLING OF PROTECTED HEALTH INFORMATION At Blue Cross, your protected health information is handled in a number of different ways as we administer your health plan benefits. The following examples show you the various uses we are permitted by law to make without your authorization:

Treatment. We may disclose your protected health information to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers) who request it to aid in your treatment. We may also disclose your protected health information to these health care providers in our effort to provide you with preventive health, early detection and disease and case management programs.

Payment. To administer your health benefits, policy or contract, we must use and disclose your protected health information to determine:

➔ Eligibility ➔ Claims payment ➔ Utilization and management of your benefits ➔ Medical necessity of your treatment ➔ Coordination of your care, benefits and other

services ➔ Responses to complaints, appeals and

external review requests We may also use and disclose your protected health information to determine premium costs, underwriting, rates and cost-sharing amounts, provided that no genetic information may be used for underwriting purposes.

Health care operations. To perform our health plan functions, we may use and disclose your protected health information to provide programs and evaluations, such as:

➔ Health improvement or health care cost-reduction programs

➔ Competence or qualification reviews of health care professionals

➔ Fraud and abuse detection and compliance programs

➔ Quality assessment and improvement activities and outcomes evaluation

➔ Performance measurement and outcome assessments, health claims analysis and health services outreach

➔ Case management, disease management and care coordination services

We may also disclose your protected health information to Blue Cross affiliates and business associates (such as Delta Dental or Prime Therapeutics) that perform payment activities and conduct health care operations on our behalf.

Service reminders. We may contact you to remind you to obtain preventive health services or to inform you of treatment alternatives and/or health-related benefits and services, which may be of interest to you.

ADDITIONAL USES AND DISCLOSURES In certain situations, the law permits us to use or disclose your protected health information without your authorization. These situations include:

Required by law. We may use or disclose your protected health information, as we are required to do so by state or federal law, including disclosures to the U.S. Department of Health and Human Services. Also, we are required to disclose your protected health information to you in accordance with the law.

Public health issues. We may disclose your protected health information to an authorized public health authority for public health activities in controlling disease, injury or disability. For example, we may disclose your protected health information to the childhood immunization registry.

Abuse or neglect. We may make disclosures to government authorities concerning abuse, neglect or domestic violence as required by law.

Health oversight activities. We may disclose your protected health information to a government agency authorized to conduct health care system or governmental procedures such as audits, examinations, investigations, inspections and licensure activity.

Legal proceedings. We may disclose your protected health information in the course of any legal proceeding, in response to a court order or administrative judge and, in certain cases, in response to a subpoena, discovery request or other lawful process.

Law enforcement. We may disclose your protected health information to law enforcement officials. For example, disclosures may be made in response to a warrant or subpoena or for the purpose of identifying or locating a suspect witness or missing persons or to provide information concerning victims of crimes.

Coroners, medical examiners funeral directors and organ donations. We may disclose your protected health information in certain instances to coroners and medical examiners during their investigations. We may also disclose protected health information to funeral directors so that they may carry out their duties. We may disclose protected health information to organizations that handle donations of organs, eyes or tissue and transplantations. For example, if you are an organ donor, we can release records to an organ donation facility.

Research. We may disclose your protected health information to researchers only if certain established measures are taken to protect your privacy. For example, we may disclose to a teaching university to conduct medical research.

To prevent a serious threat to health or safety. We may disclose your protected health information to the extent necessary to avoid a serious and imminent threat to your health or safety or to the health or safety of others.

Military activity and national security. We may disclose your protected health information to armed forces personnel under certain circumstances, and to authorized federal officials for national security and intelligence activities.

Correctional institutions. If you are an inmate, we may disclose your protected health information to your correctional facility to help provide you health care or to provide safety to you or others.

Workers' compensation. We may disclose your protected health information as required by workers' compensation laws.

Others involved in your health care. Unless you notify us in writing, we may disclose certain billing information to a family member who calls on your behalf. The kind of information we will disclose is the status of a claim, amount paid and payment date. We will not, however, disclose medical information, such as diagnosis or the name of the provider.

Your employer. If your coverage is through your employer, we may disclose information to your employer to review group claims data or to conduct an audit. All information that could be used to identify specific participants is removed unless such identification is necessary.

YOUR AUTHORIZATION Any uses and disclosures not described in this notice, including most uses and disclosures of psychotherapy notes, the use and disclosure of protected health information for marketing purposes, and the sale of any protected health information, will require your written authorization except where permitted by law. Keep in mind that you may cancel your authorization in writing at any time.

YOUR RIGHTS Blue Cross would like you to know that you have additional rights regarding your protected health information. Your additional rights are described below:

Your right to request restrictions. You have the right to request restrictions on the way we handle your protected health information for treatment, payment or health care operations as described in the "Permitted handling of protected health information" section of this notice. The law, however, does not require us to agree to these restrictions. If we do agree to a restriction, we will send you a written confirmation and will not use or disclose your protected health information in violation of that restriction. If we don't agree, we will notify you in writing.

Your right to confidential communications. We will make every effort to accommodate reasonable requests to communicate with you about your protected health information at an alternative location. For our records, we need your request in writing, except in emergency situations where verbal requests will be accepted. It is important that you understand that any payment or payment information may be sent to the original address in our records.

Your right to access. You have the right to receive (or request that a designated person receive), by written request, a copy of your protected health information that is contained in a "designated record set," with some specified exceptions. For example, if your doctor determines that your records are sensitive, we may not give you access to your records. You also have the right to request an electronic copy

of protected health information that is maintained electronically.

What is a designated record set? It's a group of records used to administer your health benefits, including:

➔ Enrollment ➔ Payment ➔ Claims adjudication ➔ Case or medical management records

Your right to amend your protected health information. You have the right to ask us to amend any protected health information that is contained in a "designated record set." For our records, your request for an amendment must be in writing. Blue Cross will not amend records in the following situations:

➔ Blue Cross does not have the records you want amended

➔ Blue Cross did not create the records that you want amended

➔ Blue Cross has determined that the records are accurate and complete

➔ The records have been compiled in anticipation of a civil, criminal or administrative action or proceeding

➔ The records are covered by the federal Clinical Laboratory Improvement Act

If you have requested an amendment under any of these situations, we will notify you in writing that we are denying your request. You have the right to file a written statement of disagreement with us, and we have the right to rebut that statement. Please note that changes of addresses are not required in writing.

Your right to information about certain disclosures. You have the right to request (in writing) information about any times we have disclosed your protected health information for any purpose other than the following exceptions:

➔ Treatment, payment or health care operations as described in the "Permitted handling of protected health information" section of this notice

➔ Disclosures that you or your personal representative have authorized

➔ Certain other disclosures, such as disclosures for national security purposes

The requirement that we provide you with information about any times we have disclosed your protected health information applies for six years from the date of the disclosure. This applies only to disclosures made on or after April 14, 2003.

Your right to receive notifications of breaches of protected health information. In the event of any unauthorized acquisition, use or disclosure of your unsecured protected health information (a "breach"), Blue Cross will notify you of such breach, unless there is a low probability that your protected health information has been compromised.

FUTURE CHANGES Although Blue Cross follows the privacy practices described in this notice, you should know that under certain circumstances these practices could change in the future. For example, if privacy laws change, we will change our practices to comply with the law. Should this occur:

➔ We will post a new notice on our website bluecrossmn.com by the effective date of the new notice and will also provide a copy of the new notice, or information about the new notice and how to obtain the new notice, in our next annual mailing to members

➔ The changes will apply to all protected health information we have in our possession, including any information created or received before we change the notice

QUESTIONS & ANSWERS

Q: Will you give my protected health information to my family or others?

A: We will share your protected health information with others only if either of these apply: 1. You are present, in person or on the telephone, and give us permission to talk to the other person, or 2. You sign an authorization form. You should know, however, that state laws do not allow us to disclose certain information about minors − even to their parents.

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

F7676R09 (10/17)

Q: Who should I contact to get more information or to get an additional copy of this notice?

A: For additional information, questions about this Notice of Privacy Practices, or if you want another copy, please visit the Blue Cross website at bluecrossmn.com. You may also call us at (651) 662-8000 with questions or to obtain forms.

Q: What should I do if I believe my privacy rights have been violated?

A: If you think that we may have violated your privacy rights, or you disagree with a decision we made about access to your protected health information, you may either:

1. Call us at the number listed above

2. File a written complaint with our Privacy Officer, Jane McMahon at the following address:

Privacy Officer Blue Cross and Blue Shield of Minnesota P.O. Box 50821 St. Paul, MN 55150-0821

3. Contact the Minnesota Department of Commerce at (651) 296-2488

4. Contact the Minnesota Department of Health toll free 1-800-657-3916

5. Notify the Secretary of the U.S. Department of Health and Human Services (HHS). Send your complaint to:

Office for Civil Rights U.S. Department of Health and Human Services 233 N. Michigan Ave., Suite 240 Chicago, IL 60601 Voice Phone (312) 886-2359, toll free 1-800-368-1019 Fax (312) 886-1807 or TTY (312) 353-5693.

6. Call the HHS Voice Hotline number at 1-800-368-1019

Please be assured that we will not take retaliatory action against you if you file a complaint about our privacy practices either with us or HHS.

Delta Dental of Minnesota is independent from Blue Cross and Blue Shield of Minnesota. Delta Dental® provides administrative services for dental benefits.

Prime Therapeutics LLC is an independent company providing pharmacy benefit management services.

Blue Cross and Blue Shield of Minnesota And Blue Plus P.O. Box 64560 St. Paul MN 55164-0560 (651) 662-8000 / (800) 382-2000

NOTICE OF OUR FINANCIAL INFORMATION PRIVACY POLICIES AND PRACTICES

We are dedicated to protecting the privacy of your nonpublic personal financial information, which we collect and maintain. Nonpublic personal financial information is information we have gathered that identifies you. This notice briefly outlines what information we collect, how we protect it and how we may disclose it. We will provide notice to you of relevant changes in our practices.

Information we collect and maintain

We collect nonpublic personal financial information about you such as your name, address, and bank information if you have Pay-It-Easy from sources such as:

• Applications or other forms you submit to us

• Providers or other insurance companies

• Others in the process of administering benefits.

How we protect information

We do not disclose nonpublic personal financial information about our customers or former customers except as permitted by law. We maintain physical, electronic, and procedural safeguards that comply with legal requirements to guard your nonpublic personal financial information.

Information we may disclose

We may disclose any of the nonpublic personal financial information we collect, at different times. You can be assured that we disclose only the information that we believe is needed for a specific purpose.

Companies to whom we may disclose information

We may disclose your nonpublic personal financial information to our affiliates and to nonaffiliated third parties as permitted or required by law, such as the following types of businesses:

• Insurers and other businesses involved in the sale or servicing of insurance products, such as life insurers, insurance agents and brokers

• Health care providers

• Government regulatory agencies

• Companies that perform services on our behalf.

What organizations are covered by this notice

This notice applies to information collected and maintained about customers of the following companies:

• Blue Cross Blue Shield of Minnesota

• HMO Minnesota d/b/a Blue Plus

Questions

If you have any questions, please contact customer service at the number on the back of your member ID card. For a copy of our Notice of Privacy Practices, visit the Blue Cross Blue Shield website at bluecrossmn.com or call the number listed on the back of your member ID card.

F7303R05 (9/15)

Bluecrossmn.com Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.